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Saving Lives Through Clinical Research | 1

ForewordFifty years ago, Singapore took baby steps into the sphere of clinical research

to deliver better health care to its population. From its origins as a low-cost manufacturer to powering the economy through knowledge and innovation,

clinical research has also undergone tremendous advances as our country progresses.

On the occasion of our nation’s 50th anniversary, we look back with pride and awe at the momentous transformations in our field. During the last half century, we have achieved significant milestones in clinical research, many having direct impact on saving and extending the lives of our population.

All of these are testaments to the unwavering dedication and progress made by Singapore’s research community. We owe many therapeutic breakthroughs to the unsung heroes who have powered medical advances and continue the search to forge new innovations for the future.

Saving Lives Through Clinical Research: A 50-Year Journey of Singapore’s Scientific Leadership is our tribute to these impactful research projects and looks at the future for clinical research. Let us celebrate the thrill of scientific discovery and the triumph of translating that discovery into improvements in human health and quality of life.

We hope this commemorative book strengthens your understanding on the importance of clinical research and enhances your appreciation for the significant part that it plays in the advancement of medical care for all of us. And we welcome you to share it with anyone who has an interest in learning more about this field, as we continue to embark on Saving Lives through Clinical Research.

Associate Professor Teoh Yee Leong CEO, Singapore Clinical Research Institute (SCRI)


Contents

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Foreword

Evolution of medical researchin Singapore

50 years of transformingmedical research

Stories of leaders

Early researchers sow the seeds

Controlling Hepatitis B - a Singapore success story

Providing hope for kidney patients

The Singapore eye

Conquering cancer

Caring for our children

Singapore’s ageing population - how will we manage?

How to keep our aspirations highin an ever-changing landscape

Optimising the clinical trials landscape

Making great strides

An evidence-based approach to medicine

Saving lives through clinical research - fulfilling the promise

The BMS initiative - an engine of Singapore’s economy

Academic medical centres crucial to the mix


Evolution of medicalresearch in Singapore

Dr Charles Toh

As Singapore’s economy has transformed over the past five decades, so has its biomedical sciences sector. Founding Chairman of the National Medical Research Council and former Vice-Dean of the Faculty of Medicine, University of Singapore, from 1969 to 1972, Dr Charles Toh, charts the fascinating journey of medical research in Singapore.

Singapore from the 1960s to the 1980s was certainly a different place than what it is now. The Budget at a

national level was much tighter, so there was little funding for medical research. There was a shortage of laboratories

and research scientists. If research was conducted, it was mostly at a personal level, by clinicians with a passion for such endeavour. It tended to involve studies of local disease patterns (epidemiology), or small drug trials.

In the early 1990s, the Singapore government made the enlightened decision to fund medical research at an unprecedented level – leading to the creation of the National Medical Research Council (NMRC) by the Ministry of Health (MOH). The Medical Director then was Dr Kwa Soon Bee. I still remember the day he rang me at my clinic and asked if I was willing to lead this new organisation. After carefully thinking about it for two days I decided to accept the offer!

Together with a team of our top local researchers, the NMRC sets about its work of helping to grow Singapore’s research culture. One of our major challenges at the beginning was to find reviewers for research protocols submissions of more than $250,000, or for atypical projects. There were not enough local expert

reviewers in Singapore, so we sought the assistance of internationally recognised reviewers. This was also essential for the fact they were independent and unlikely to have biases. In particular, we were very grateful to the contributions of the Canadian Medical Research Council and the Walter and Eliza Hall Institute of Medical Research in Melbourne, Australia.

As a whole, clinical research offers so many important benefits. It enlightens the researcher in the areas studied, encourages more critical thinking and translates into better healthcare for our community. Epidemiological research also provides a broader perspective of our health care issues compared to other countries. This ultimately translates into a more rational long-term spending in healthcare. Building new and impressive research fund infrastructure has certainly helped us to develop and advance clinical research and health care in Singapore.


Clinical research has contributed significantly to improving the lives of patients.

Presented are the remarkable collection of perspectives on the story of clinical research and healthcare in Singapore from key leadership persona within Singapore’s biomedical sciences sector.

These vignettes unveil little-known anecdotes about the evolution of clinical research, its impact in improving the lives of our people and eradicating diseases.

Stories of leaders


Early researchers sow the seeds

Dr Charles Toh

clinical research helps enlighten the clinician’s mind to think more deeply beyond the disease of the single patient.

Singapore’s ability to contribute large numbers of patients to clinical trials is limited by its relatively small population. However, our neighbouring countries do have high populations which we may be able to leverage. The impressive research fund infrastructure we have built over the years – which includes entities such as the

National Medical Research Council and the National Cancer Centre Research Fund – is certainly helping us to develop and advance clinical research and healthcare in Singapore.

What kind of clinical research trials were you involved in, early in your medical career?

Early in my career, in the 1960s to 1970s, my colleagues and I concentrated largely on studies of clinical disorders peculiar to this region, and some advances in medical and surgical therapies. We focused on hypertension and its complications, diabetes and infectious diseases. Later, as Singapore’s population aged, we became progressively more interested in coronary artery disease.

What are some of the drivers that have enabled clinical research in Singapore to flourish?

There are several factors which have contributed to the expansion of Singapore’s clinical research sector. First, there was a growing appreciation that clinical research should be a part of clinical training for doctors. Increasingly, academic clinicians were recruited based on their research credentials.

Furthermore, large multinational drug trials have fostered strong collaborative arrangements between our researchers

and others in the region or internationally, and advances in information technology and information transfer have made it easier for such cooperative research to take place.

Importantly, high levels of funding and support from the Singapore government and its agencies, drug companies, tertiary institutions, and charitable organisations have helped us to achieve our dreams for greater expansion of medical research.

How does clinical research contribute to the advancement of healthcare for patients?

Clinical research provides sound evidence-based data upon which one can derive healthcare and clinical diagnostic and treatment decisions. Epidemiological studies give a better idea of the patterns of disease and changes, and which treatment approaches are working well in our particular setting. In that sense,

In addition to being the founding Chairman of the National Medical Research Council, Dr Charles Toh has held many senior level roles in Singapore’s medical establishment. From his clinic at Mt Elizabeth Medical Centre, he reflects on how clinical research here has progressed over the past 50 years in Singapore.

Professor Chia Boon Lock at Coronary Care Unit in SGH in 1973 (Credit: NHCS) Coronary Care Unit in 1960s (Credit: NHCS)

“Clinical research provides sound evidence-based data upon which one can derive healthcare and clinical diagnostic and treatment decisions”


Controlling Hepatitis B – a Singapore success story

Long-standing veteran in epidemiological surveillance and research, Professor Goh Kee Tai works at the Ministry of Health and Saw Swee Hock School of Public Health, National University of Singapore. He has been a part of many a Singapore success story, including that of Hepatitis B.

Singaporeans have faced many major health – related challenges from communicable diseases over the

past five decades and beyond, notably epidemics of polio in the 1950s and 1960s, the high disease burden of Hepatitis B virus infection in the 1970s and 1980s, and the SARS pandemic in 2003 come to mind. While polio and SARS are no longer immediate threats, Hepatitis B virus infection has remained endemic. Chronic Hepatitis B virus infection is a precursor risk factor to liver cancer, one of the most common types of cancers in Singapore.

According to Professor Goh, the incidence of acute Hepatitis B and prevalence of Hepatitis B virus carriers in Singapore have fallen substantially, due to the inclusion of the Hepatitis B vaccine in the national childhood immunisation programme in the 1980s.

“The impact [of immunisation] has been tremendous. We know that vaccines are a very powerful public health tool. And the immunisation programme has been successfully implemented with effective results. Singapore has a good

health infrastructure, and its people are committed [to protecting their families and getting themselves immunised].”

The Hepatitis B vaccine became available in the 1980s. By the early 1990s, the proportion of Singaporean children getting immunised was around 70-80 percent, and subsequently jumped to more than 95 percent from the mid-1990s onwards. (Figure on page 11)

This high, near universal Hepatitis B vaccination coverage rate in the 1990s may also be attributed to Singapore clinical research. When Hepatitis B vaccine first became commercially available, it

was costly. As a result, the Ministry of Health funded a clinical trial evaluating the effectiveness of a lower dose in infants. Prof Goh and his colleagues conducted several trials, which involved children and adults. It was found that half the usual full dose of the vaccine recommended by the manufacturer was just as effective at preventing Hepatitis B virus infection as a usual dose. As a consequence of these clinical studies, a half-dose was initiated in Singapore, rather than the full dose. The cost of the vaccine was reduced substantially and as a result, more Singaporeans were able to be immunised.

“As a consequence of these clinical studies, a half-dose was initiated in Singapore, rather than a full dose. The cost of the vaccine was reduced substantially and as a result, more Singaporeans were able to be immunised”

Professor Goh Kee Tai

Figure: Incidence of Acute Hepatitis B per 100,000 population and vaccination coverage among Singapore children at 2 years of age, 1985-2013 (Source: Communicable Diseases Division, Ministry of Health)

Primary school children being tested for post Hepatitis B vacinnation immunity

More primary school children being tested for post Hepatitis B vacinnation immunitya

Source: The Straits Times, 9 April 1988 © Singapore Press Holdings Limited. Permission required for reproduction.


Going forward, there are several exciting advancements and directions being explored in nephrology, and we should be proud that Singapore’s clinical researchers are at the forefront of many of these investigations and discoveries.

Providing hope forkidney patients

In the 1990s, Professor Woo Keng Thye, Emeritus Consultant in the Department of Renal Medicine at SGH and a Clinical Professor in Medicine at NUS, helped launch Singapore’s Good Clinical Practice Guidelines. From 2003-2006, Prof Woo served as Chairman of the National Medical Research Council. He is also known for his work as a kidney disease researcher.

The specialty of nephrology – the study of the kidney and its ailments – can be traced back to the 1970s

in Singapore, when most research was trying to work out the underlying causes of different types of kidney disease.

In the late 1980s and 1990s, nephrologists in Singapore began to become interested in a condition called IgA Nephritis, the most common form of kidney disease locally. Patients with IgA Nephritis were found to be at high risk of thrombogenicity (formation of clots) in the kidneys leading to kidney failure. We conducted clinical trials to test the hypothesis of whether antithrombotic drugs could delay the onset of kidney failure. The clinical trial findings were positive. Upon publishing our results, many countries adopted the use of these drugs in their treatment guidelines for IgA Nephritis, hence benefitting and saving many patients.

Later in the 1990s, we tested a new class of medicines called Angiotensin Receptor Blockers (ARBs), which had become available in several countries for lowering blood pressure. These were also found to be effective in preventing kidney failure in patients with IgA Nephritis. As a result of our work, Singapore’s clinicians were among the first in the world to use ARBs in patients for such a purpose.

Over the decades, clinical research has helped boost the hopes of millions suffering from kidney diseases around the world. In addition to drug development, researchers are trying to improve existing lifesaving technologies such as haemodialysis and invent completely new devices for kidney patients that simulate artificial kidneys. Advances in transplantation care have led to better renal transplant survival rates and, since the turn of the century, genomics research has provided new genetic insights in almost all forms of kidney diseases.

Did you know?

A portable kidney dialysis machine will soon undergo clinical trials for the first time in Singapore. Using this wearable artificial kidney, patients can be more mobile and provided with a convenient option.

Professor Woo Keng Thye

Haemodialysis machine with built-in monitor in the 1980s. (Credit: SGH)

Old SGH Attic dialysis centre established in 1968. (Credit: SGH)

“Over the decades, clinical research has helped boost the hopes of millions suffering from kidney diseases around the world”

Modern-day dialysis machine. (Credit: SGH)


How did eye research get started in Singapore and what has spurred its growth?

The ethos of doing research here was established 25 years ago by our founding Medical Director Professor Arthur Lim, who passed away last year. Prof Lim set up the Singapore National Eye Centre (SNEC) at the request of the Ministry of Health. Right from the start, he promoted

research initiatives and helped set up the Singapore Eye Research Institute (SERI). One of the main reasons why ophthalmology is so vibrant in this research culture is the awareness that doing clinically applied research enables one to effect better patient care and better patient outcomes. What the West does in eye care does not always apply as well to Asian populations due to their genetic differences. This has paved the way for high impact research to improve how eye diseases can be treated and prevented; not just for Singaporeans or Asians, but on a global scale.

What eye disorders have clinical researchers focused on in Singapore?

Over the last two decades, we have conducted important trials into eye diseases, which are more common in Asians such as pterygium surgery, myopia, angle-closure glaucoma, cataract and infectious keratitis.

How does such research benefit the public?

It is all about improving eye care, or even preventing ocular disease. This is especially important for childhood myopia. Singapore, like most Asian countries, has a high prevalence of myopia

and our randomised clinical trials (ATOM Study) using low dose atropine eyedrops to prevent myopia progression in children is now the most effective treatment available. We are also targeting the major conditions that can result in blindness in the elderly, such as glaucoma, diabetic retinopathy and age-related macular degeneration. Our research is focused on preventative strategies, early detection and treatment.

How will Singapore take the lead in eye research going forward?

There are several exciting research initiatives underway. We are devising new surgical and medical innovations to treat corneal disease and glaucoma.

For corneal disease, we have developed surgical devices and new forms of corneal transplantation, and in glaucoma, nanoparticle sustained-release drug delivery therapy. SERI is also running

the world’s largest ocular infections study called ACSIKS (Asia Cornea Society Infectious Keratitis Study), that includes more than 6,500 patients across eight countries in Asia. We anticipate the results of this study to have a profound effect in enabling us to identify what type of antibiotics should be used to treat infectious keratitis in the Asian population. Again, it is a disease of Asian significance. So we are taking the lead.

Professor Donald Tan has contributed to more than two decades of eye research and is a pioneer of modern corneal transplantation surgery. Now, as Arthur Lim Professor in Ophthalmology at the Ophthalmology and Visual Sciences Academic Clinical Program of Duke-NUS, he sees a bright future ahead for Singapore’s clinical eye research efforts.

Professor Donald Tan

The Singapore eye

Did you know?

The ATOM Study conducted in 2006-2012 by SNEC and SCRI in 400 children showed that by giving a low dose Atropine eye drop every day, it helps to slow down the progression of myopia in our children who are already myopic. This ground-breaking clinical research result has benefited many of our children today, as they have been started on this medicated eye drop to slow down the progression of their myopia.

SNEC sets its sights on being a leader in clinical service, research and teaching. Prof Donald Tan explaining the finer points of corneal transplantation. (Credit: SNEC)

The Singapore National Eye Centre (Credit: SNEC)

“Singapore, like most Asian countries, has a high prevalence of myopia and our randomised clinical trials (ATOM Study) using low dose atropine eyedrops to prevent myopia progression in children is now the most effective treatment available”

� MYOPIAEye research success: Atropine eye dropsthat slow childhood myopia.What it is: Eye drops that use atropine toslow the progression of myopia inchildren. Traditionally used to treat achildhood condition called “lazy eye”.The results so far: Progression of myopiacan be halted in the first year oftreatment and reduced by half in thesecond year, studies have found.What next: Ongoing research into using alower dosage of the drug to reduce theside effects of glare.

Eye research success: Vision-trainingcomputer software.

� What it is: A program calledNeuroVision that improves mild myopiaby training the brain to “sharpen” theimages seen by the eye.The results so far: After 30 minutes oftraining every other day over 10 weeks,children in one trial could read anaverage of two lines further down atypical 11-tier eye chart.What next: A larger trial involving fourschools that will begin in February.

� CORNEAL BLINDNESSEye research success: World’s first stemcell transplants.What it is: Transplants that use mastercells, known as stem cells, to grow eyetissue.

The cells are taken from a healthy eyeand used to grow specialised tissue forthe cornea – the transparent front partof the eye that covers the pupil – andthe surrounding white area.

Damage to this eye surface is thesecond leading cause of blindness in theworld, after cataracts.

Traditional methods involvetransplanting tissue from donors ortissue grown from animal cells.The results so far: 45 patients treated.

Eye research success: Asia’s firsttooth-in-eye surgery.What it is: A last-ditch procedure to cureblindness when treatments such as stemcell grafts and cornea transplants fail.

It involves implanting the patient’stooth – in which a hole has been drilled– in the eye socket. A plastic cylinder isplaced in the hole to focus light onto theretina at the back of the eye.

The procedure is suitable for peoplewhose eyes have been damaged bydisease or injury, but whose optic nervesare intact.The results so far: 25 patients treated.

Singapore produces 71 million kg of waste glasseach year, but only 9 per cent is recycled. The restis incinerated with other waste. To boost recyclingrates, Singapore Polytechnic’s Centre forApplications in Environmental Technology hasteamed up with glass collection facility P&RResource Management to find ways of makingrecycling safer, quieter and more convenient.Grace Chua takes a look at the current process.

R E C Y C L I N G B O T T L E S

GLASS ACT

BY LIAW WY-CIN

SINGAPORE punches above its weight ineye research, according to an internation-al journal which has ranked it as the mostproductive country in such research,when adjusted for population size.

The International Ophthalmology jour-nal found that from 2002 to 2006, Singa-pore produced 20.49 publications for eve-ry one million people, placing it in the topspot, ahead of research heavyweightssuch as Britain and the United States.

While the US had the highest annualand total contributions, it ranked seventhon the list of countries most prolific ineye research when adjusted for popula-tion size.

One reason Singapore is so big on eyeresearch is its vested interest. Morechildren here become short-sighted andmore quickly so than anywhere else in theworld.

Myopia is the most common eyeproblem here and in Asia; some 80 percent of teenagers here are short-sighted,said chairman of the Singapore Eye Re-search Institute (Seri), Professor DonaldTan.

About 95 per cent of the total amountof eye research done in Singapore iscarried out by Seri, said Prof Tan.

The institute partners public hospitals,universities and public science research in-stitutes to study areas such as myopia,glaucoma, corneal blindness and diabe-tes-linked blindness.

Eye research is one of five areas of fo-cus under Singapore’s current biomedicalsciences research push, said the executive

director of the National Medical ResearchCouncil (NMRC), Dr Edwin Low.

Said Dr Low: “A rigorous and positiveresearch environment is necessary tobring about better research outcomes,which will eventually be translated to bet-ter patient care.

“This is the environment that Seri hassuccessfully built up over the years andone that the NMRC highly encourages.”

Last year, Seri appointed an interna-tional advisory panel to review itsprogress and to benchmark it against the

top eye research centres in the world.The panel pitted Seri’s work against

that of three institutions – the Johns Hop-kins University’s Wilmer Eye Institute,the University College London’s (UCL) In-stitute of Ophthalmology; and the Univer-sity of Melbourne’s Centre for Eye Re-search Australia (CERA).

The first two are leaders in NorthAmerica and Europe, while the Australiancentre was picked because it was “in ourpart of the world” and had a similar annu-al budget for eye research as Seri, said

Prof Tan.The panel found that Seri ranked sec-

ond among the four in the number of re-search papers published in top scienceand medical journals such as Nature andthe New England Journal of Medicine.

From the years 2002 to 2006, Seri had64 such papers in top journals, JohnsHopkins had 54, UCL had 146 and CERAhad 33.

But for that same period, Seri pub-lished the most number of papers amongthe four institutes – 428 papers, largely in

journals on eye disease.Prof Tan said the international recogni-

tion serves to validate the 10-year-old in-stitute’s work.

It also helps it map a strategic plan forthe institute over the next 10 years.

“We know where we stand on an aca-demic level. We now want to study the im-pact of our research on improving eyecare in Singapore and the rest of theworld,” said Prof Tan.

He said the institute hopes to put out areport on this in the next three months.

4 After heating and mixing, gobs of molten glass are moulded into bottles andcontainers. New bottles, which contain up to 70 per cent recycled glass come off the

line to begin life again as beer and drink containers.

1 Glass bottles, mainly from restaurants, coffee shops and other F&B establishments inSingapore are sent to collection facilities such as P&R Resource Management in Sungei

Kadut, which handles about 500,000kg of glass each month. Most are beer bottles, and afaint smell of the brew lingers in the air. At the company’s collection yard, a forklift breaksthe bottles by lifting a trough of glass up and pouring it from a height. The crash and clangcan reach an ear-splitting 130 decibels, louder than a jet engine.

Key projectsin progress at Seri

2 P&R’s parent company,silicate-sand mining

firm PUM Group, has arecycling facility at PasirGudang in Johor, Malaysia.Bottles and glass chunksare trucked and shippedthere from as far away asThailand, Indonesia and NewZealand. They will eventuallybe crushed into smaller,finger-length glass shardsand recycled into newbottles. Part of the processinvolves workers separatingimpurities such as paperand metal from the crushedglass chips.

3 Different colouredchips – green, amber

and flint (colourless) – areseparated by machine. Atglass-bottle factory MalayaGlass, this machine, calledthe “dog-house”, sends theraw material – a mixture ofrecycled glass chips, sodaash, limestone and otheringredients – into thefurnace to be heated attemperatures of up to 1,600deg C for 24 hours.

S’pore most prolific in world for eye research per capita

ST PHOTOS: SAMUEL HE

Extreme myopia is not just inconvenient, but itcould also end in blindness. FILE PHOTO: ZAOBAO

THE STRAITS TIMES SATURDAY, DECEMBER 20 2008 PAGE D10science■

Source: The Straits Times, 20 December 2008 © Singapore Press Holdings Limited. Permission required for reproduction


tissue must be minimised. At the behavioral level, we have to understand why people make decisions that increase their cancer risk. “One of the biggest challenges in cancer management is prevention, getting

people to go for appropriate screening, and helping people understand that they are responsible for actions which affect their own health,” says Wong.

“When I look at the amount of talent we’ve been able to bring into the public healthcare system for cancer research, it is mind-boggling. Some of our best and brightest students are really getting inspired to enter this field. I think we’ve created an ever increasing cycle of talent.”

Cancer research in Singapore dates back decades. In the 1950 and 60s, faculty such as Professor

K. Shanmugaratnam, worked on the epidemiology and pathology of cancers seen in Singapore and established the Singapore Cancer Registry. In the 1970s

and 80s, Professors Chan Soh Ha and Oon Chong Jin worked on Hepatitis B and Hepatocellular cancer, and Professor Lee Hin Peng made major contributions to dietary factors in the development of cancer and the control of cigarette smoking. Fast forward to the current millennium and we have an explosion of cancer research, including Professor Chia Kee Seng’s work on cancer epidemiology; Professors Daniel Tenen, Phillip Koeffler, Toshio Suda, Teh Bin Tean, Hong Wan Jin, Edison Liu, and Bing Lim’s work on the molecular biology of cancer; Associate Professor Yeoh Khay Guan, Professors Lawrence Ho, Yoshiaki Ito and Patrick Tan’s work on gastric cancer; Associate Professors Goh Boon Cher, Chng Wee Joo, Lee Soo Chin, Allen Yeoh, Tan Eng Huat, Toh Han Chong, and Lim Soon Thye’s work on developing better treatment options; and Professor Soo Khee Chee’s work in surgical oncology have all placed Singapore on the world map as a major site for cancer research.

According to Prof John Wong, a medical oncologist-haematologist who leads the National University Health System (NUHS) as its Chief Executive, people make all the

difference. “Singapore has been blessed to have some really brilliant faculty. There are people with a keen interest in understanding the disease, trying to improve prevention, early diagnosis, and developing better treatment. People are key.” Prof Wong says other important factors include training, infrastructure, funding, and collaboration with academics and industry globally.

“The management of cancer is very complex,” says Prof Wong. At the cellular level, the interplay of factors is substantial, with challenges not only in identifying key pathways, but also overcoming tumor resistance. Even if successful treatment is developed, collateral damage to normal

Singapore cancer research has a long and proud history, and the future is bright, says leading oncologist Professor John Wong, Chief Executive, National University Health System (NUHS). A well-known cancer researcher, he is also Senior Vice President (Health Affairs) of the National University of Singapore (NUS).

Professor John Wong

Conquering cancer

Did you know?

Singapore researchers were one of the first to show that Non-Small Cell Lung Cancer (NSCLC) in different patient populations can respond differently to the same treatment in 1996. A study found that the response rate to docetaxel–carboplatin chemotherapy was significantly higher but more toxic in Asian compared to Caucasian patients. It is now widely accepted that drug response and toxicity profiles may be influenced by ethnic differences, hence contributing to the field of ethnic pharmacology.

“Some of our best and brightest students are really getting inspired to enter this field. I think we’ve created an ever increasing cycle of talent”

NUS Yong Loo Lin School of Medicine has been nurturing the doctors of Singapore over the past 110 years. (Credit: NUHS)

National University Health System building (Credit: NUHS)

By SumathiSelvaretnam

SEVERAL town councilsare taking the initiative toimprove the lot of their es-tate cleaners, and are work-ing with the NationalTrades Union Congress(NTUC) and the WorkforceDevelopment Agency.

The 14 PAP town coun-cils want their conservan-cy workers to go through atraining programme, so

they can improve theirskills and earn better sala-ries.

Dr Teo Ho Pin, Mayor ofNorth West District andchairman of the town coun-cils’ Job Re-creation Pro-gramme Committee, ob-served yesterday that clean-ing contractors were not fo-cused on upgrading the skillsof their workers because ofkeen competition and pricecutting.

T h r e e h u n d r e dfull-time PAP town coun-

cil conservancy workerswill attend a four-daycourse conducted by theNTUC LearningHub.

Some of the things theywill learn include how toclear and wash drains andperform cleaning services.The best performers inthe course, which startsnext week, can expect a 5 to10 per cent pay raise – thismeans about $35 to $75more a month on a meanwage of $750.

All 4,000 local conserv-ancy workers will have un-

dergone the programmeby 2010.

The town councils willstart to award perform-ance-based conservancycontracts from next year.

New specifications in thecontracts include recom-mended starting salaries,monthly Central ProvidentFund contributions and flexi-ble work hours.

Dr Teo said: “We haveset up a tender evaluationsystem where we recogniseboth the price and perform-ance of contractors. In thatway, we are able to awardcontracts based on val-ue-for-money and not nec-essarily the lowest tender.”Post your comments online atwww.straitstimes.comCatch our free video report atwww.straitstimes.com

MANY people start thinking ofhealth insurance only whenthey get seriously ill. That’swhen it may be too late.

Financial advisers say thereare three kinds of plans oneshould have to tide over unex-pected health-care costs: Me-diShield or enhanced Shieldplans to take care of hospitalisa-tion costs; disability insurance;and critical illness plans to en-sure an income if you cannotwork for a prolonged period.

The top must-have is Me-diShield or its enhanced ver-sions, the Shield plans.

This week’s issue of Mind

Your Body delves into thetricky topic of health insurance,with financial experts helpingyou to figure it out.

Also covered in this issue isa form of dyslexia in which thebrain cannot process certainwavelengths of light. Learnhow a pair of blue-tinted specta-cles helped to change a boy’slife.

By Wong Chun Han

INITIAL clinical trials havebeen successfully completedon a new cancer treatmentdrug here.

The drug, known asABT869, has less severeside effects than alternativetreatments.

Clinical trials, involving21 advanced-stage cancerpatients, concluded in De-cember last year.

The study, undertakenby a team of local medicalprofessionals and research-ers on behalf of internation-al health-care company Ab-bott, also marked a newmilestone in Singapore’s de-velopment as a cancer re-search centre.

This was because it wasthe first early-phase clinical

trial involving human test-ing to be carried out in thecountry.

The aims of the trial in-cluded establishing a safedosage, understanding thedrug’s behaviour in the hu-man body and its possibleside effects on patients suf-fering from various types ofcancer.

The second phase, whichwill begin in Singapore atthe end of this year, will fo-cus specifically on thedrug’s ability to battle liverand lung cancer.

The study was led byDr Goh Boon Cher, a seniorconsultant at the Cancer In-stitute at the National Uni-versity Hospital.

According to Dr Goh,the development of thedrug follows a new trend incancer drug research, whichfocuses on drugs that targetcancer-promoting proteins.

The new drug specifical-ly prevents the growth ofnew blood vessels whichfeed the cancer cells, there-by indirectly inhibiting the

growth of tumours.Given its highly specific

effects, which reduce dam-age to normal cells, the treat-ment is considered more ad-vantageous than chemother-apy.

Patients can also be kepton the new treatment forlonger periods.

The drug’s high potencyin targeting a spectrum ofproteins and the absence oflong-term side effects setthe drug apart from othersimilar drugs of its type, add-ed Dr Goh.

Patients in the study ex-perienced side effects suchas rash, increased bloodpressure and fatigue. Butthese were more managea-ble compared to those asso-ciated with chemotherapy.

Because it is orally admin-istered, the drug also reduc-es hospital treatment times,thus enabling improvedtreatment lifestyles for pa-tients.

Despite the apparent ben-efits, Dr Goh refused to becarried away. He said: “Al-

though the drug showsgreat promise, its effective-ness in comparison withother drugs remains to beseen.”

Singapore’s excellent re-search and medical infra-structure and high-qualityhealth-care services wereimportant factors in Ab-bott’s decision to conductthe study here, accordingto Mr Cihangir Kosu, Ab-bott’s regional director forSouth-east Asia.

He added that Singa-pore’s multi-ethnic popula-

tion was also a major con-sideration, since it allowedthe study of the drug’s effec-tiveness across variousAsian ethnicity.

The second phase of thedrug study will involveabout 40 to 60 lung and liv-er cancer patients.

Professor Edison Liu, ex-ecutive director of the Sin-gapore Cancer Syndicate,believes Abbott’s expan-sion of the study indicatesthat Singapore possessesthe right expertise and re-sources to attract firms to

conduct early-stage clinicaltrials.

An important gain fromconducting such trials hereis the quicker access for pa-tients to new experimentaldrugs, he said.

A typical drug develop-ment process could take upto 10 years to complete.

The trials would thusprovide new alternatives atan earlier time to patientswho have exhausted otherforms of treatment.

[email protected]

Post your comments online atwww.straitstimes.com

Town councils step in tobetter the lot of cleaners

By Zakir Hussain

THE National Parks Board(NParks) has told gay interestgroup People Like Us that it cannothold a picnic and a 5km run at theBotanic Gardens. The picnic wasscheduled for tomorrow, and therun, on Saturday.

NParks said it did not want thegardens “to be used as a venue forinterest groups to politicise theircause”.

Organisers have called off thepicnic, at which people were towear pink.

Said organiser Miak Siew: “Peo-ple are going to be there having apicnic anyway. It’s just a socialthing; it’s a picnic, not a protest.”

As for the run, it is likely to takeplace outside the gardens, said MrSiew, 32, an IT project manager.

Both events are part of an annu-al series organised by gay groupshere.

NParks’ decision comes less thana week after the Home Affairs Min-istry cancelled a permit for a publicforum on gay issues, at which oneof the speakers was a foreigner, Ca-nadian professor Douglas Sanders.

One of the points the ministrymade was that discourse on domes-tic issues was for Singaporeans on-ly. The event went ahead yester-day, with local speakers.

On the latest decision, NParkstold The Straits Times it was alertedto the events by a member of thepublic and saw details on the web-site run by People Like Us.

In an Aug 3 letter to gay activistAlex Au, Botanic Gardens directorChin See Chung said: “As theevents are advertised, they are con-sidered organised gatherings.” Per-mission from NParks is required forsuch gatherings “in our parks andgardens”, he added.

Explaining its decision to TheStraits Times, NParks said: “TheSingapore Botanic Gardens is a pre-mier botanical institution. We donot want it to be used as a venuefor interest groups to politicise theircause...Let’s keep our green spaceas areas for relaxation and recrea-tion.”

PHOTO: NATIONAL UNIVERSITY OF HOSPITAL

NEW HOPE: Dr Goh Boon Cher of the Cancer Institute led the study. The drug, ABT869,prevents the growth of new blood vessels that feed cancer cells, inhibiting tumour growth.

First early-phasetrial on humans aboost for S’pore’sresearch status

Cancer drugtrial yieldspromising results

No gofor gaypicnic, runat BotanicGardens

Sort out yourhealth cover

H6 HOME THE STRAITS TIMES WEDNESDAY, AUGUST 8 2007

Source: The Straits Times, 08 August 2007 © Singapore Press Holdings Limited. Permission required for reproduction


health. “Factors that contribute include a much cleaner Singapore, better education, greater awareness of health hygiene and improved social behaviour,” he adds.

Prof Phua and many of his colleagues have also been at the forefront of clinical research. In collaboration with his colleagues, he helped test a vaccine for Rotavirus. Rotavirus infection can cause severe diarrhoea in infants and young children. It has a mortality of half a million children worldwide annually – mostly in the third world. Globally, death from rotavirus has decreased significantly with the introduction of the Rotavirus vaccine. Rotavirus induced diarrhoea is still common amongst paediatric patients in

Singapore. However, with administration of the vaccine, the disease in immunised babies and young children has become milder and they may not need to seek medical attention, or be admitted to hospital.

“While many diseases have almost disappeared from Singapore, ‘diseases of affluence’ such as obesity, inflammatory bowel disease, diabetes and asthma are on the rise,” says Prof Phua. Researchers are monitoring these trends and clinical research will no doubt play an important role in the future in defining Singapore paediatric care.

Paediatrics in Singapore has undergone major changes over the past five decades, in large part

due to technological advances. The profession has also evolved from one that was a general discipline to one that now features multiple subspecialties. The number of paediatricians in Singapore has also grown substantially.

When Professor Phua Kong Boo, Senior Consultant at KK Women’s and Children’s Hospital (KKH), started practising in 1967, Singapore General Hospital (SGH) was the only public hospital providing specialist paediatric services.

Over the subsequent decades however, paediatrics departments sprang up in other major hospitals, including the National University Hospital (NUH), Tan Tock Seng Hospital (TTSH) and Alexandra Hospital (AH). From the late 1970s, Singapore paediatricians began to develop subspecialty interests and the practice of subspecialisation expanded greatly when all the public hospital paediatric departments were consolidated and moved to KKH in 1997.

At the same time as Singapore’s paediatric profession evolved, Singapore modernised and transformed into a developed country and its infant mortality rate improved significantly over the decades. “In 1967, it was 24.8 [per 1,000 resident live births]. Now it’s only 2.0 per 1,000 – comparing favourably with other developed countries,” according to Prof Phua. Child health care has improved by leaps and bounds since the 1960s, with improvements in neonatal care and advances in medical care, knowledge and technology. The environment has also changed to positively impact paediatric

As a pioneer in the field of paediatrics in Singapore, Professor Phua Kong Boo, has seen the remarkable evolution of the profession since the 1960s. He reflects on these changes and the achievements of Singapore paediatric clinician researchers.

Professor Phua Kong Boo

Caring for our children

“While many diseases have almost disappeared from Singapore, ‘diseases of affluence’ such as obesity, inflammatory bowel disease, diabetes and asthma are on the rise”

Did you know?

In the early 2000s, a large pharmaceutical company partnered with the public healthcare institutions such as KKH, NUH and several polyclinics to conduct the largest clinical trial in Singapore - involving more than 9,000 infants for the Rotavirus vaccine Phase 2 and then Phase 3 trial. The strong private public partnership contributed to the success of this landmark trial, facilitating the Rotavirus vaccine to be licensed in Singapore in 2005, ahead of other key global regulatory agencies. To this day, the vaccine continues to help protect children in Singapore.

Kandang Kerbau Hospital, 1940s, with Bukit Timah Road and canal in the foreground. Note the trishaws and the road bridge over the canal. (Credit: ‘The history of obstetrics and gynaecology in Singapore’ Tan K. H. & Tay E. H. (eds.) (2003))

The main block and entrance of the New Wing of the old Kandang Kerbau Hospital. (Credit: ‘The history of obstetrics and gynaecology in Singapore’ Tan K. H. & Tay E. H. (eds.) (2003))

The current KK Women’s and Children’s Hospital built in 1997. (Credit: KKH)


Singapore has come a long way over the past 50 years in terms of healthcare delivery, for which it

ranks very highly in worldwide surveys. However, the current model of care we have in place is unsustainable as it emphasises on episodic illness care. We need to adapt and refocus our system of care in order to better face the challenges of the future, especially with respect to our aging population. Our ultimate goal – to help people live and die well.

Part of this will involve revisiting some key fundamentals of public health and working out how to encourage Singaporeans to live better in order to avoid, or slow the progression of chronic diseases. It also means improving the transition of elderly patients from our hospitals, when stabilised, into the community and step-down care facilities, where they can be looked after by caregivers, friends and family. We have found that for community care

to be effective, patients often need a combination of medical and social support services. Effective integration of such care services is therefore vital. We also need to invest further in the quality of palliative care delivery in order to help patients and their families cope better when a loved one is entering the last phase of his or her life. We need to look at what are the best ways for trained medical professionals and healthcare workers to have open conversations and channels of communication with patients and their families early in the process.

Looking into the future, we would like to expand our focus from just illness to wellness care. This spells a massive paradigm shift for our healthcare system. We need to develop evidence-based approaches. Collaboration between clinicians and researchers is therefore important to ensure that our new model of care is both strategic and sustainable. I believe that Clinician Scientists and

Professor Philip Choo has one of the most important jobs in Singapore’s healthcare system – leading the National Healthcare Group as its Group CEO. Best known for his outstanding contributions during the SARS crisis, Prof Choo is also one of Singapore’s pioneering geriatricians and maintains a healthy interest in meeting the needs of the nation’s aging population.

Professor Philip Choo

Singapore’s ageing population -how will we manage?

researchers will play a key role in Health Services research – in helping Singapore achieve what no other country has been able to – a sustainable new model of effectively targeted healthcare which is high quality and well managed for our entire population.

Geriatrics Team-based care today. (Credit: NHG)

Therapist in the Rehabilitation Centre at Mandalay Road in the 1980s. (Credit: TTSH)Tan Tock Seng wards before the 1960s. (Credit: TTSH)

“Collaboration between clinicians and researchers is therefore important to ensure that our new model of care is both strategic and sustainable”


Singapore initiated the current expansion drive of its biomedical sciences sector in the year 2000.

Fifteen years on, it is timely to look back at what has been achieved, as well as ahead to what challenges or changes will be required to foster further progress.

The intent has always been to transform Singapore into a life science hub in the region. While we have come some way towards doing so for Southeast Asia; elsewhere in Asia, much larger countries and economies such as China and Korea have progressed significantly in this area. The biomedical sciences capabilities of those countries have experienced very rapid growth, because the investments and the size of their population are much larger.

The question therefore is what should Singapore’s biomedical sciences sector aspire to be in a landscape that is

continuously evolving at a rapid pace? On the clinical research side, Singapore has enough infrastructure and the capabilities to compete with other research hubs internationally, and is well-positioned to facilitate the development and implementation of new health innovations.

In 2015, our clinical research is beginning to have an impact in the market, either in terms of health outcomes, or economically. More funding will be required to bring health innovations to market. Singapore continues to attract industry and can potentially be a hub that

Chairman of NMRC and former Dean of Duke-NUS Graduate Medical School Singapore, and a distinguished scientist in his own right, Professor Ranga Krishnan continues to play a leading role in charting Singapore’s clinical research trajectory. Prof Krishnan talks about our prospects and the challenges of keeping our aims high.

Professor Ranga Krishnan

How to keep our aspirations high in an ever-changing landscape

is able to influence the development and planning of clinical trials in the Southeast Asia region.

A lot of the supporting infrastructure needed is already in place and we are very strong in many therapeutic areas, especially eye care, oncology and cardiology. The push in the biomedical sector is a long-term strategic process and Singapore is examining new ways to integrate and further enhance its capabilities. Part of this will involve ramping up current initiatives to train more physicians to be clinician scientists.

There is still a hill to climb. But the good news is we have come a long way from our humble beginnings to this point.

“There is still a hill to climb. But the good news is we have come a long way up from our humble beginnings to this point”

With seven years as Duke-NUS Dean under his illustrious belt, Professor Ranga Krishnan has passed the mantle over to Professor Thomas Coffman. (Credit: Duke-NUS)

Professor Ranga Krishnan (second from left) shares a light-hearted moment with alumni from the M.D. Class of 2011. (Credit: Duke-NUS)


How are medical schools and hospitals collaborating in academic medicine?

There are two broad directions. First, hospitals and medical schools collaborate

in order to recruit adequate numbers of patients for clinical trials. The second kind of collaboration is between hospitals and basic translational laboratories. We aim to foster an environment in which clinicians deeply embedded in their practice can articulate unresolved clinical questions, and then form a strong team of basic and translational scientists to address those issues. We are trying to reverse the traditional order of collaboration with a ‘bed to the [laboratory] bench’, rather than a ‘bench to the bed’ approach.

How important is clinical research to academic medical centres?

Clinical research is extremely important. It helps to address the unanswered problems that we encounter daily in our practice, and therefore is relevant to clinical application. In addition, participating in clinical research helps keep physicians at the cutting edge. It encourages them to be challenged intellectually and to think of new ideas to solve the problems they encounter.

Clinical research is the application of these ideas. It keeps physicians vibrant as a community.

How important has the growth in funding for Singapore’s biomedical sector been for clinical research?

The expansion sends the signal that the government is committed to research as an end in itself, rather than as a means to an end. It has provided sorely needed funding in order for research to be undertaken. Modern medical research, especially clinical research and clinical trials, is extremely expensive because of the strict rigour that is required for good research. A well-designed phase III trial costs millions of dollars.

This expansion of funding through the biomedical sciences initiative is essential. It signals to the rest of the world Singapore’s strong intention and projects our image as a world leading medical centre.

As the Deputy Group CEO (Research and Education) of SingHealth and Founding Director of the National Cancer Centre Singapore (NCCS), Professor Soo Khee Chee has spearheaded cutting edge clinical research in SingHealth. Prof Soo talks about the importance of Academic Medical Centres to research endeavours.

Professor Soo Khee Chee

Academic medical centres crucial to the mix


Ensuring that new medicines are effective and safe is crucial for public health. Clinical trials are a critical pre-

requisite for this. However, the nature of clinical research means that this can be very expensive and time-consuming, requiring the input of many people and institutions across the public and private sectors, and different geographic and national jurisdictions.

Singapore’s Ministry of Health (MOH) has done much to provide local clinical researchers with support over the years. The Clinical Trials & Epidemiology Research Unit (CTERU) was first established in November 1996, and later restructured to become the SCRI in September 2008.

SCRI is fortunate to have benefited from the leadership of notable members of our healthcare and research community over the years, as well as long serving experts. Professor John Wong, Chief Executive of

the National University Health System, and Professor Ranga Krishnan, Chairman of the National Medical Research Council (NMRC) and former Dean of Duke-NUS Graduate Medical School Singapore, chaired the Board on a rotational basis between 2009 to 2014 and provided visionary guidance for SCRI’s development. Associate Professor Tan Say Beng, former NMRC Executive Director, was also Director of CTERU and SCRI’s Chief Scientific Officer, and helped define its strategic direction. Associate Professor Edwin Chan, SCRI’s current Chief Scientific Officer and Head of Epidemiology, has been a dedicated member of the team since the CTERU days.

Building on the foundation of CTERU’s initial goals, SCRI has adapted to rapid changes in the clinical trial arena. It has evolved beyond its traditional role as an Academic Research Organisation into a facilitative organisation partnering healthcare and medical research bodies to

Associate Professor John Lim, Deputy Director of Medical Services (Industry & Research Matters) at the Ministry of Health and Executive Director of the Centre of Regulatory Excellence (CoRE) at the Duke-NUS Graduate Medical School Singapore is Chairman of the SCRI. As the former CEO of the Health Sciences Authority, whose remit includes the regulation of clinical trials in Singapore, he reflects on the important role of the Institute since its inception and its plans for the future.

A/Professor John Lim

Optimising the clinicaltrials landscape

build our national research infrastructure. Today, SCRI works closely with the NMRC to optimise the clinical trials landscape, and promote greater coordination and collaboration.

Clinical research is a global undertaking. Large clinical trials are run in different countries around the world and in this region, the role of SCRI in managing clinical research beyond Singapore is assuming greater significance.

Singapore’s biomedical sciences sector has expanded exponentially over the last few decades and is a key pillar of the economy. Most of this rapid growth has taken place in the past 15 years, with the Government’s farsighted investment in the vision of transforming Singapore into a regional life sciences hub.

Over the ten year period from 2002 to 2011, the number of employees working in

Singapore’s biomedical sciences research community grew by two and a half times – from just over 2,000 to nearly 5,500, including about 100 clinician scientists. Currently, around 7,000 researchers carry out biomedical sciences research and development work in Singapore. This is spread across more than 50 private companies, in our world-class universities, and in 30 public-sector institutions under A*STAR and MOH.

Looking to the future, SCRI – with its dedicated senior management and expert staff – is committed to being an integral component of Singapore’s biomedical and health research infrastructure, supporting the nation’s economic development, the body of clinical science knowledge and the delivery of excellent healthcare to our population.

The pioneers of SCRI


I joined the Clinical Trials and Epidemiology Research Unit (CTERU) in the late 90s, during an exciting time

when there was an enlightened policy to invest in clinical research infrastructure in Singapore.

The CTERU, set up in 1996 with funding from the Ministry of Health (MOH),

was the precursor to the SCRI and a prominent product of that visionary policy – a part of a deliberate strategic imperative to support and fast track the development of Singapore’s clinical research infrastructure. CTERU provided clinical researchers in Singapore’s public sector with access to a critical limiting resource - a cohesive multidisciplinary team of biostatisticians, data managers, epidemiologists, IT specialists, research monitors and project managers. Complementing them were clinical research processes, SOPs, computer hard and software and core funding.

The EBM ‘tsunami’ was lapping at the shores of Singapore and clinicians, medical educators and researchers had to internalise this new paradigm.

EBM is first and foremost about a mind-set that is constantly questioning and critically evaluating the basis for existing clinical practice. If empirical evidence appears to be lacking, then that presents an opportunity to perform research to fill in those knowledge gaps.

I feel privileged to be part of the local effort to train young clinicians in the core skills needed to practice EBM in Singapore

and to have worked alongside many other like-minded clinicians and researchers.

Looking to the future, I see some real opportunities for Singapore to excel in clinical research. One emergent area that I am particularly excited about is medical devices. Unlike drugs which are limited by our ability to discover what nature has produced, devices are invented and can leverage off the collective inventive genius and technological skill set of a wider spectrum of research scientist-engineers.

I see great potential for Singapore to achieve success in medical device innovation. We have the right environment here and I think we could really achieve significant successes.

Associate Professor Edwin Chan is a leading proponent for evidence-based medicine (EBM) and currently serves as a Chief Scientific Officer and Head of Epidemiology at the Singapore Clinical Research Institute (SCRI). He speaks about the rapid rise of clinical research in Singapore and offers a few thoughtful insights about the future.

A/Professor Edwin Chan

An evidence-basedapproach to medicine

“EBM is first and foremost about a mind-set that is con-stantly questioning and criti-cally evaluating the basis for existing clinical practice”


As a whole, clinical research offers so many important benefits. It enlightens the researcher in the areas studied, encourages

more critical thinking and translates into better healthcare for our community.

Dr Charles Toh

The past 50 years have seen major clinical advances in Singapore. Studies conducted have had profound

impacts on medicine and provided hope for many patients. These achievements are a testament to Singapore’s research community.

As we continue to relentlessly build on the discoveries of the past, we hope the stories in this book inspire Singaporeans to recognise the vast and beneficial impact that clinical research brings to each of our lives.

The impact [of immunisation] has been tremendous. We know that vaccines are

a very powerful public health tool.

Professor Goh Kee Tai

Looking into the future, we would like to expand our focus from just illness to wellness care. This

spells a massive paradigm shift for our healthcare system.

Professor Philip Choo

Going forward, there are several exciting advancements and directions being explored in nephrology, and we should

be proud that Singapore’s clinical researchers are at the forefront of many of these investigations and discoveries.

Professor Woo Keng Thye

One of the main reasons why ophthalmology is so vibrant in this

research culture is the awareness that doing clinically applied research enables

one to effect better patient care and better patient outcomes.

Professor Donald Tan

Researchers are monitoring [disease] trends and clinical research will no doubt play an important role

in the future in defining Singapore paediatric care.

Professor Phua Kong Boo

I see great potential for Singapore to achieve success in medical

device innovation.

A/Professor Edwin Chan

Looking to the future, SCRI – with its dedicated senior management and expert staff – is committed to being an integral component of

Singapore’s biomedical and health research infrastructure, supporting the nation’s economic development, the body of clinical science

knowledge and the delivery of excellent healthcare to our population.

A/Professor John Lim

This expansion of funding through the biomedical sciences initiative is

essential. It signals to the rest of the world Singapore’s strong intention and projects our image as a world leading

medical centre.

Professor Soo Khee Chee

Some of our best and brightest students are really getting inspired to enter

this field. I think we’ve created an ever increasing cycle of talent.

Professor John Wong

There is still a hill to climb. But the good news is we have come a long way up from our humble

beginnings to this point.

Professor Ranga Krishnan

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Saving lives through clinical research - fulfilling the promise

foreword - scri · foreword f ifty years ago, singapore took baby steps into the sphere of clinical...

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